Interview with Michael Harvey Ph.D., Clinical Psychologist
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Topic: Patients Who Need Hearing Aids -- But Don't Want Them!
Beck: Hi Dr. Harvey. It's a pleasure to speak with you again.
Harvey: Hi Dr. Beck. Nice to speak with you, too.
Beck: Would you please tell me how you got involved with this unique area of counseling, working with deaf and hard of hearing people?
Harvey: Thirty years ago, I was working in California, and I was getting bored with my job. As it happens, my wife was taking a sign language course, and I quickly became enamored with sign language. I realized that taking one sign language course was sort of like eating one potato chip! So, I got involved with sign language and soon after that, we moved back home to Boston. I applied for a job as executive director of an agency that worked with signing deaf people, and I was hired. After a couple years working with deaf people, I learned that culturally deaf people believe deafness is a difference to be accepted, and not a deficit to be corrected. And then I learned about important differences between that group and those who have lost their hearing, or who are hard-of-hearing. I And so for the last 20 years or so, I've also worked with HOH and those with acquired hearing loss.
Beck: And that really is a major difference, as we're getting to the core of how people identify themselves, and which truths they hold as dear. If you identify yourself as a deaf person, you are making different choices and different claims than people who identify themselves as hearing people.
Harvey: Yes, that's correct. For self-defined "hearing-impaired" people, not being able to hear well is a loss, a deficit, naturally leading to grieving. Not so with many culturally deaf persons who consider themselves a linguistic minority.
Beck: In your clinical experience, is there a "number one" issue that most people with hearing loss have to address? In other words, is there a common counseling theme among HOH people, with regard to addressing and managing their hearing loss?
Harvey: One core issue is self-esteem and a fragile sense of self. That is related to a common fear about losing more hearing, living with anxiety and feeling disconnected. You know, the Helen Keller quote that blindness separates you from things; deafness separates you from people.
Beck: And of course, self-esteem is a common issue not just for HOH people, but for healthy emotional and developmental issues too -- really for all of us!
Harvey: Absolutely. I refer to these self-esteem issues as an internalized handicap. The handicap or disability may originate with hearing loss, but the internal handicap occurs when people believe they are inferior, it's the attitude secondary to the hearing loss, and that becomes the self-esteem issue and deficit. Some clinicians refer to this as "negative self-talk."
Beck: Michael, what can you tell me about your term "Ordinary Evil?"
Harvey: What I call Ordinary evil is behavior by another(s) that feels evil, but not enough to make it on CNN. I sent out a questionnaire and got amazing responses from HOH people dealing with rejection, rudeness, oppression, ridicule, bullying....and all of those things are easily remembered years later by the victim. It's a huge deal to the individuals involved - often quite traumatic - but you're not gonna see it on the news. In a statistical sense, it's ordinary. It's how people with hearing loss, or any kind of disability, are often treated. And many people with hearing loss attribute a huge chunk of their distress to ordinary evil - to be distinguished from well-meaning ignorance - by hearing persons around them.
Beck: I think you're absolutely right, and that gets to the stigma associated with hearing loss and wearing hearing aids. OK, I know your time is limited, so let me change subjects a little.....What can you tell me about motivational interviewing?
Harvey: Motivational interviewing is a directive, patient-centered counseling style used to help patients explore and resolve ambivalence. It comes from working with people with drug and alcohol problems who are ambivalent and frequently resistant about change. These are often people who go to well meaning doctors, and the doctors tell them what to do, and the patient says "thank you very much" and then the patient leaves without any intention of changing. And I have applied the techniques used with these people to hearing loss patients. You know better than I do Doug, that many of the patients you see really need hearing aids, they would do much better with hearing aids, but they really don't want hearing aids - or are, at best, ambivalent.
Beck: That's what many of us deal with every day. We see the patients, we diagnose the patients, and we know how to help them regarding their hearing loss, but they really don't want us to fit them with hearing aids.
Harvey: Which puts you in the same position as physicians. About half the patients will never get their prescriptions filled. The physicians know the diagnosis, they know how to treat it, but about half the patients will walk out the door and not bother to fill the script or do what the doctor says.
Beck: What do we do about this lack of compliance?
Harvey: Well, first of all, it's important not to be in such a rush to help. This may feel like a paradox at best, since that's what you're there for and have been trained to do. There's a cartoon in a well-known psychotherapy text of a patient walking into the office backwards. It's as if to say, "I want your help but don't want your help." When a provider adopts the help position, the patient will often adopt the other side of the ambivalence: the "I don't want help" position.
The framework of Motivational Interviewing also outlines how to elicit so-called "self motivational" statements from the patients.
Beck: For example?
Harvey: There are four kinds of self-motivational statements which you can elicit: problem recognition, expression of concern, intention to change, and degree of self-confidence to change. As an example of the first, you might say to the patient "How do you feel when you don't hear the words clearly?" Then again, you might say something like "Who would benefit the most if you were to get hearing aids?" Or, "How important is it for you to get your hearing improved right now?" Through this dialogue about feelings - without trying to fix the "problem" so quickly -- the patient to take ownership of the problem and to define their issues a little more clearly. Many audiologists shy away from this because it feels like psychotherapy. It isn't. It's a kind of exploratory, respectful, collaborative dialogue which, in fact, is very therapeutic and often results in increased patient adherence to audiologic recommendations.
Beck: OK, very good. Michael, suppose I have an 82 year old male in the office, a WWII veteran, he has a sensorineural loss, moderate to severe, with word recognition of 64 percent. I tell him the results of the exam, and then he says "Thanks Doc. I hear what I wanna hear. The world can speak louder if they wanna talk to me."
Harvey: That's a common scenario.
Beck: That's what most of us face every day! I can't recall the last time someone jumped up and down and was so excited to learn that they needed to wear hearing aids! Generally, we deal with lots of denial and frustration.
Harvey: Right, and I said before, it's a common but, from my point of view, error to list all the reasons why that patient should get amplification. So instead you can adopt the position of curiosity. You become respectfully curious; you stop knowing so much and ask questions. You might ask the patient, "How does it feel to hear what I'm telling you?" And yes, if you look at a transcript of the resulting dialogue, it certainly may resemble the dialogue that happens in psychotherapy. But it isn't. It's a kind of dialogue that can empower patients as the expert on their emotional issues with hearing loss and, as such, the audiologic visit can become, what I have called, a "transformative experience." In other words, there are emotional benefits to an audiologic visit, far beyond diagnosing and treating one's hearing loss.
Beck: There's a lot more to this, obviously. Thank you for including some of your article references which provides more information. And I understand that you provide workshops and training for audiologists and hearing care professionals on what we've talked about?
Harvey: Absolutely. I enjoy doing training very much. People can contact me by phone or email.
Beck: Michael, as always it is a pleasure speaking with you and I wanna thank you so much for your time today. I want to be sure to recommend that all audiologists read your books - The Odyssey of Hearing Loss and Listen with the Heart. I can say without reservation, I learned a lot reading them! We'll list them at the end of the interview so they can be easily found.
Harvey: Thank you too Doug. It's always fun working with you too, and I appreciate the opportunity to reach your audience.
----------------
To contact Dr. Michael Harvey
Send e-mail to mharvey2000@comcast.net
or telephone 508-872-9442. His website URL is www.michaelharvey-phd.com.
Dr. Harvey's books include Listen with the heart: relationships and hearing loss. (2001) and The odyssey of hearing loss: tales of triumph (1998). Both are published by: Dawn Sign Press in San Diego, CA. These books contain true stories from his psychotherapy practice with individuals, couples and families. The user-friendly, story-telling format illustrates in detail how psychological, social and spiritual factors are interwoven to shape one's experience of hearing loss and that of significant others. It is relevant reading for professionals and consumers.
Other articles include:
Harvey, M.A. (2003). Audiology and motivational interviewing: A psychologist's perspective. www.audiologyonline.com.
Harvey, M.A. (2003) When a patient requests hearing aids but doesn't want them: Psychological strategies of managing ambivalence. Feedback. 14(3), 7-13.
Harvey, M.A. (2003). A dying father helps his daughter to live. Hearing Review, 10(4), 34-37, 80.
Harvey, M.A. (2002). Trout fishing: the gentle art of persuasion with hard-of-hearing adolescents. Hearing Review, 9(11), 40-55.
Harvey, M.A. (2000). The transformative power of an audiology visit. Hearing Journal. 53(2), 43-47.
Harvey: Hi Dr. Beck. Nice to speak with you, too.
Beck: Would you please tell me how you got involved with this unique area of counseling, working with deaf and hard of hearing people?
Harvey: Thirty years ago, I was working in California, and I was getting bored with my job. As it happens, my wife was taking a sign language course, and I quickly became enamored with sign language. I realized that taking one sign language course was sort of like eating one potato chip! So, I got involved with sign language and soon after that, we moved back home to Boston. I applied for a job as executive director of an agency that worked with signing deaf people, and I was hired. After a couple years working with deaf people, I learned that culturally deaf people believe deafness is a difference to be accepted, and not a deficit to be corrected. And then I learned about important differences between that group and those who have lost their hearing, or who are hard-of-hearing. I And so for the last 20 years or so, I've also worked with HOH and those with acquired hearing loss.
Beck: And that really is a major difference, as we're getting to the core of how people identify themselves, and which truths they hold as dear. If you identify yourself as a deaf person, you are making different choices and different claims than people who identify themselves as hearing people.
Harvey: Yes, that's correct. For self-defined "hearing-impaired" people, not being able to hear well is a loss, a deficit, naturally leading to grieving. Not so with many culturally deaf persons who consider themselves a linguistic minority.
Beck: In your clinical experience, is there a "number one" issue that most people with hearing loss have to address? In other words, is there a common counseling theme among HOH people, with regard to addressing and managing their hearing loss?
Harvey: One core issue is self-esteem and a fragile sense of self. That is related to a common fear about losing more hearing, living with anxiety and feeling disconnected. You know, the Helen Keller quote that blindness separates you from things; deafness separates you from people.
Beck: And of course, self-esteem is a common issue not just for HOH people, but for healthy emotional and developmental issues too -- really for all of us!
Harvey: Absolutely. I refer to these self-esteem issues as an internalized handicap. The handicap or disability may originate with hearing loss, but the internal handicap occurs when people believe they are inferior, it's the attitude secondary to the hearing loss, and that becomes the self-esteem issue and deficit. Some clinicians refer to this as "negative self-talk."
Beck: Michael, what can you tell me about your term "Ordinary Evil?"
Harvey: What I call Ordinary evil is behavior by another(s) that feels evil, but not enough to make it on CNN. I sent out a questionnaire and got amazing responses from HOH people dealing with rejection, rudeness, oppression, ridicule, bullying....and all of those things are easily remembered years later by the victim. It's a huge deal to the individuals involved - often quite traumatic - but you're not gonna see it on the news. In a statistical sense, it's ordinary. It's how people with hearing loss, or any kind of disability, are often treated. And many people with hearing loss attribute a huge chunk of their distress to ordinary evil - to be distinguished from well-meaning ignorance - by hearing persons around them.
Beck: I think you're absolutely right, and that gets to the stigma associated with hearing loss and wearing hearing aids. OK, I know your time is limited, so let me change subjects a little.....What can you tell me about motivational interviewing?
Harvey: Motivational interviewing is a directive, patient-centered counseling style used to help patients explore and resolve ambivalence. It comes from working with people with drug and alcohol problems who are ambivalent and frequently resistant about change. These are often people who go to well meaning doctors, and the doctors tell them what to do, and the patient says "thank you very much" and then the patient leaves without any intention of changing. And I have applied the techniques used with these people to hearing loss patients. You know better than I do Doug, that many of the patients you see really need hearing aids, they would do much better with hearing aids, but they really don't want hearing aids - or are, at best, ambivalent.
Beck: That's what many of us deal with every day. We see the patients, we diagnose the patients, and we know how to help them regarding their hearing loss, but they really don't want us to fit them with hearing aids.
Harvey: Which puts you in the same position as physicians. About half the patients will never get their prescriptions filled. The physicians know the diagnosis, they know how to treat it, but about half the patients will walk out the door and not bother to fill the script or do what the doctor says.
Beck: What do we do about this lack of compliance?
Harvey: Well, first of all, it's important not to be in such a rush to help. This may feel like a paradox at best, since that's what you're there for and have been trained to do. There's a cartoon in a well-known psychotherapy text of a patient walking into the office backwards. It's as if to say, "I want your help but don't want your help." When a provider adopts the help position, the patient will often adopt the other side of the ambivalence: the "I don't want help" position.
The framework of Motivational Interviewing also outlines how to elicit so-called "self motivational" statements from the patients.
Beck: For example?
Harvey: There are four kinds of self-motivational statements which you can elicit: problem recognition, expression of concern, intention to change, and degree of self-confidence to change. As an example of the first, you might say to the patient "How do you feel when you don't hear the words clearly?" Then again, you might say something like "Who would benefit the most if you were to get hearing aids?" Or, "How important is it for you to get your hearing improved right now?" Through this dialogue about feelings - without trying to fix the "problem" so quickly -- the patient to take ownership of the problem and to define their issues a little more clearly. Many audiologists shy away from this because it feels like psychotherapy. It isn't. It's a kind of exploratory, respectful, collaborative dialogue which, in fact, is very therapeutic and often results in increased patient adherence to audiologic recommendations.
Beck: OK, very good. Michael, suppose I have an 82 year old male in the office, a WWII veteran, he has a sensorineural loss, moderate to severe, with word recognition of 64 percent. I tell him the results of the exam, and then he says "Thanks Doc. I hear what I wanna hear. The world can speak louder if they wanna talk to me."
Harvey: That's a common scenario.
Beck: That's what most of us face every day! I can't recall the last time someone jumped up and down and was so excited to learn that they needed to wear hearing aids! Generally, we deal with lots of denial and frustration.
Harvey: Right, and I said before, it's a common but, from my point of view, error to list all the reasons why that patient should get amplification. So instead you can adopt the position of curiosity. You become respectfully curious; you stop knowing so much and ask questions. You might ask the patient, "How does it feel to hear what I'm telling you?" And yes, if you look at a transcript of the resulting dialogue, it certainly may resemble the dialogue that happens in psychotherapy. But it isn't. It's a kind of dialogue that can empower patients as the expert on their emotional issues with hearing loss and, as such, the audiologic visit can become, what I have called, a "transformative experience." In other words, there are emotional benefits to an audiologic visit, far beyond diagnosing and treating one's hearing loss.
Beck: There's a lot more to this, obviously. Thank you for including some of your article references which provides more information. And I understand that you provide workshops and training for audiologists and hearing care professionals on what we've talked about?
Harvey: Absolutely. I enjoy doing training very much. People can contact me by phone or email.
Beck: Michael, as always it is a pleasure speaking with you and I wanna thank you so much for your time today. I want to be sure to recommend that all audiologists read your books - The Odyssey of Hearing Loss and Listen with the Heart. I can say without reservation, I learned a lot reading them! We'll list them at the end of the interview so they can be easily found.
Harvey: Thank you too Doug. It's always fun working with you too, and I appreciate the opportunity to reach your audience.
----------------
To contact Dr. Michael Harvey
Send e-mail to mharvey2000@comcast.net
or telephone 508-872-9442. His website URL is www.michaelharvey-phd.com.
Dr. Harvey's books include Listen with the heart: relationships and hearing loss. (2001) and The odyssey of hearing loss: tales of triumph (1998). Both are published by: Dawn Sign Press in San Diego, CA. These books contain true stories from his psychotherapy practice with individuals, couples and families. The user-friendly, story-telling format illustrates in detail how psychological, social and spiritual factors are interwoven to shape one's experience of hearing loss and that of significant others. It is relevant reading for professionals and consumers.
Other articles include:
Harvey, M.A. (2003). Audiology and motivational interviewing: A psychologist's perspective. www.audiologyonline.com.
Harvey, M.A. (2003) When a patient requests hearing aids but doesn't want them: Psychological strategies of managing ambivalence. Feedback. 14(3), 7-13.
Harvey, M.A. (2003). A dying father helps his daughter to live. Hearing Review, 10(4), 34-37, 80.
Harvey, M.A. (2002). Trout fishing: the gentle art of persuasion with hard-of-hearing adolescents. Hearing Review, 9(11), 40-55.
Harvey, M.A. (2000). The transformative power of an audiology visit. Hearing Journal. 53(2), 43-47.
